post surgery hemotoma 2

[steelhead]

Since, I can't reply back on the original post. I do have a question for patients that travel and have a hemotoma.
What are options ? As flying back is not logistically and financially possible . Do you see our regular doctor ?

[DrBermant]

Since, I can't reply back on the original post. I do have a question for patients that travel and have a hemotoma.
What are options ? As flying back is not logistically and financially possible . Do you see our regular doctor ?

Although a hematoma is a risk of any surgery, those risks can be lowered with certain techniques. Most of my practice comes from around the world, traveling for my sculpture. Preventing hematoma and other such complications became a passion to help my patients minimize travel, maximize comfort, and ease recovery.

Hematoma like bruising is a collection of blood in tissues, just to different degrees. To start out, I needed to develop standard pictures to document before and after surgery that can be used to show the effects of residual hematoma contour deformity as well as the evolution of tissues after surgery. I then evolved my surgery to knock out as much bruising as possible. The bruising seen on my website is typical for my patients. Each of my patients is seen the day after surgery. Of the few hematoma that we have had over the years, all of them have been seen right after surgery before they travel back home. I prefer to put the drains in myself. I need drains so rarely, combined with hematoma, for my chest surgery it seems to happen once every 1 to 3 years. Each of my patients is educated before surgery that if they are one of the rare one to need a drain, that management of drains from a distance is not easy and we prefer patients who need drains to stay locally until they can be removed. Each case is then analyzed to understand the cause to see if we can then lower the chance any further. That is one of the reasons I evolved the technique that all cases start at the edge of the areola so that I can directly visualize and control the bleeding. Liposuction in fat carries little risk of such bleeding. But sharp cutting of tissue needed for gland removal is a different story if you are trying to minimize bruising, bleeding, and hematoma.

Aggressive early treatment of hematoma is critical for good results. There have been many patients who have asked for my help after surgery done elsewhere. As hematoma are resolved, there can be residual deformity. Here is one such example:

I had b/l reduction mammoplasty 3 months ago for mild to moderate gynecomastia, with drains kept in place, removed 3 days after the operation. The problem is, I look exactly the same as I did pre-operatively. The surgeon told me that there are "organizing hematomas" underneath, which should re-absorb over time. This doesn't make sense to me. How can you cut out tissue from under the skin and then have the outer appearance look exactly the same as it did before having it cut out? Is this guy a moron?

The problem is that the blood must be broken down by the body. This adds to the injury process. The more blood to be broken down, the more risk of residual scar. It can take weeks to months for this process to complete. In many it never does and I then have performed revision surgery. We get back to the careful system of documentation by pictures. The multiple angles, flexing of muscles, and arms up over head as well as videos can really demonstrate subtle issues. Like residual gland, hematoma scar tissue deformity can disrupt the contour of the chest. Such issues can be hidden when the documentation is with only a limited set of pictures. I have yet to need to offer such revisions on my own patients.

So you want to deal with this without risks?  Sorry, that is not possible. We can minimize the risks as much as possible by lowering all forms of extra blood needing to be managed from bruising to hematoma. That is why I feel documentation and analysis of technique is so critical.

Hope this helps,

Michael Bermant, M.D.

[steelhead]

Thank you I take it the rest of the doctors here see hemotoma rarely as well.

[Dr. Elliot Jacobs]

Every surgeon on this planet has had a post-op hematoma -- that is, unless he is not operating at all.

Yes, there are methods to try to minimize hematomas -- precise surgery, scrupulous stoppage of all bleeding vessels, pressure garments after surgery, and yes, even drains on every case.  And yet, hematomas may occur -- even with drains in place!!

In my practice, a hematoma is exceedingly rare -- and I very rarely place a drain.  Yet, if and when it occurs, I believe in prompt action to remove the liquid or clotted blood.  When I have patients travel to see me for surgery, I request that they remain in the NYC area for a few days after surgery just to make sure that all is OK before they travel home.  Trying to manage a hematoma on a patient who has already traveled back home is difficult.

Dr Jacobs

[DrBermant]

Thank you I take it the rest of the doctors here see hemotoma rarely as well.

Remember that a hematoma and bruising are both a continuation of the same thing: blood outside of where it belongs. As hematoma resolve, the excess blood becomes bruising. So the issue at hand here is just how much bruising is there after any one methodology?  And the follow up is: how often does such bruising become severe enough to warrant intervention such as drains?  The next question is how well does the body look and move after that hematoma or that degree of bruising? That is why I worked so hard in evolving the documentation methodology so I could better understand and evolve my surgical technique for my sculpture.

Hope this helps,

Michael Bermant, M.D.

[Dr. Elliot Jacobs]

Since, I can't reply back on the original post. I do have a question for patients that travel and have a hemotoma.
What are options ? As flying back is not logistically and financially possible . Do you see our regular doctor ?

As you can see from the prior answers, the best treatment for a hematoma (remember, it is rare) is fairly rapid intervention.  Obviously, there are degrees of hematoma.  A small hematoma will disappear by itself.  A large hematoma requires surgical removal.

A late hematoma (ie a week or more after surgery), is extremely rare -- and most often due to a patient not adhering to my post-op instructions.  In these situations, treatment is best done with a local surgeon -- not a general practitioner or regular doctor.

Dr Jacobs

[Litlriki]

I also ask that patients who come from a distance stay for at least about 48 hours, which is when the risk of post-operative hematoma is greatest.  They can occur later, but that's very unusual. 

The risk of hematoma in gynecomastia patients in general is less than 1%.  A particular group of patients, namely steroid users, have a much higher risk--10 - 20% in various series.  In my own practice, the risk in that group since 1992 is 12%--at the low end, but still 10-fold higher than in non-steroid related gynecomastia, and despite me taking precautions due to the recognized increased risk. Indeed, these are the patients who travel to me most frequently, so prompt treatment is essential, as noted by Drs. Bermant and Jacobs.

One problem that can occur after hematoma--even if it's drained promptly--is delayed seroma (fluid collection), which can require aspiration.  This happened to one of my patients many years ago, who had already returned to California.  Fortunately, a friend and colleague of mine was able to see the patient for me to aspirate the seroma.  Most of us have such associates, who can help us out in such situations, but the best way to manage this problem is to avoid it in the first place.

Rick Silverman